Professor Ana Isabel Lopes – Interview

It would be easy to ask him to describe his academic and professional career until he arrived here. He chose Gastro’s specialty within Pediatrics. But what made her follow this path?

It is hard for me to describe so many years of work in a nutshell, but I should say that it is with great pride that I took up an academic and professional career focused on the great School that the Faculty of Medicine of Lisbon and the Santa Maria Hospital was and still is for me. And I acknowledge that regardless of other valid external training inputs, such as internships at international reference centres, which I have had opportunity to complete. As a medical student, a young Paediatrics intern or a paediatrician-professor-researcher, I’ve had the great privilege of knowing and learning with some of the great Masters and references of Medicine, today as ever. Exceptional individuals and decisive influences that have given me a strong imprinting of their knowledge, visionary spirit, praxis and example. I highlight, among many others, in diverse contexts and training stages, Professors A. Torres Pereira, M. Diaz Gonçalves, M. Lurdes Levy, J. Salazar de Sousa, J. Gomes Pedro, F. Coelho Rosa, Rui M. Victorino.

I received an invitation from Professor Torres Pereira and I started teaching when I was a 4th-year medical student, as a Monitor of Microbiology, taught in the 3rd year of the Medical Degree, at the beloved Camara Pestana Institute, and then I worked as a Guest Lecturer for 11 years. I started working at an early stage of my career as part of a pre-clinical subject, and I consider that as one of the most important professional experiences I ever had, which was decisive for acquiring a solid pedagogical experience (TP and P teaching). I have wistful memories of that period: the strong interaction with the students in practical classes with a rewarding feedback, the exceptional atmosphere created by the Institute’s team (professors, students, laboratory technicians).

Early on, I took up the challenges of a “hybrid” career, always pursued in a demanding and difficult balance of interests and entailing a true spirit of mission on three inseparable fronts: teaching, assistance, and research. After completing the medical degree, I completed all the stages of both careers (hospital and academic) simultaneously although, in the first years, I clearly privileged my hospital career, given the highly demanding specialisation (5 years) and paediatric subspecialisation (3 years); I was able to focus on my academic career at a later stage, especially after the doctorate.

I developed my activity in periods of great change, with an impact on clinical-scientific knowledge, on the organisation of healthcare systems, on clinical practice and on teaching models. While Clinical Medicine was always my unquestionable vocation, Paediatrics was my passion. I had no doubts when it came to choosing such a comprehensive speciality as Paediatrics (what attracted me was the fact that it was true “Internal Medicine,” with various potential subspecialisation scenarios). I had no doubts when it came to choosing the Paediatrics Service of the HSM to complete my internship, because its organisation model (departments with different units) was truly pioneering in Portugal. Throughout the internship, which is long, I was fascinated by virtually all areas of hospital Paediatrics, especially those that involved a technical component, such as Gastroenterology and Neonatology (both in a phase of great expansion). During that period, I had the opportunity to complete optional internships, namely in the areas of Neonatology and Intensive Care: Special Care Baby Unit, John Radcliffe Hospital, Oxford; Community Paediatric Department, Radcliffe Infirmary, Oxford, Neonatology Emergency Room, Paediatric Service of the S. Francisco Xavier Hospital, Special Paediatric Care Roster (HSM), 1st National Subsystem for the Transport of New-borns at Risk Roster (HSM). After completing the specialisation in Paediatrics, from among the various possible choices, I firmly chose Gastroenterology, following an invitation from Professor J Salazar de Sousa (Director of the Paediatric Service) – the founder of Portuguese Paediatric Gastroenterology and one of its great references at the international level – to join the team of the Gastroenterology Unit. In the Gastroenterology Unit, the first Portuguese school of Paediatric Gastroenterology and national reference centre, I was trained and gained experience in all its aspects (Gastroenterology, Hepatology and Nutrition, Endoscopic Techniques, Liver Biopsy, pHmetry). I completed my training with a one-year internship in Hepatology/Liver Transplantation at the Université Catholique de Louvain (Cliniques S. Luc, Brussels) (one of the largest international centres). This happened in a period in which liver transplantation was taking its first steps in Portugal, so it was a milestone in my career (I was the first Portuguese paediatrician with competence in this area), providing me with differentiated training and exposure to a clinical and research organisational model of excellence.

In the following years I completed all the formal steps of the hospital career (Applications for Hospital Assistant with Profile, Graduate Assistant, Paediatric Gastroenterologist Degree from the Medical Association and Application for Head of Paediatric Service). Nowadays, Paediatric Gastroenterology is a fascinating and very dynamic subspeciality with multiple subareas of clinical, technical and research interest. My role as Unit Coordinator has been privileging the technical and clinical differentiation of the members of the team in all their areas of intervention (Gastroenterology, Hepatology and Nutrition). It has been an extremely demanding task, as I’m directly responsible for providing assistance to all the sectors: Inpatient Unit, various Appointments, Day Hospital and Techniques, in addition to being the Paediatric Emergency Team Leader until 2012 and, since then, the Paediatric Digestive Endoscopy Prevention Roster (which I created and is the only one in southern Portugal). I also work as Coordinator and clinical manager of another Functional Unit of the Department of Paediatrics – the Techniques Unit. It is a truly pioneering Unit in Portuguese Paediatrics, and its mission is to perform diagnostic/therapeutic procedures in a paediatric environment in accordance with the highest standards.

On the other hand, and back to the academic area, after starting my internship in Paediatrics, I went from teaching Microbiology to teaching subjects in the field of Paediatrics, initially as Guest Lecturer and, after the PhD, as Assistant Professor; only years later, after entering the competition for Head of Paediatric Service and taking on the coordination of two Clinical Units/reference centres (Paediatric Gastroenterology Unit, Paediatric Techniques Unit), was it possible for me to resume the following stages of my academic career: Aggregation Exam, Associate Professor and, more recently, Full Professor. Teaching is neither an innate competence, nor derived exclusively from professional experience. It requires persistent, continuous work, including training, updating, strategy and pedagogical innovation. Under guiding principles and directives, I have shaped my own, and even intuitive, style of teaching, resulting from self-learning and a continuous search for attractive and effective approaches. The current shift in the paradigm of educational models, in view of the complexity of the challenges that are currently faced in medical education (excessive number of students, hospital constraints, etc.), is also forcing our School to address the need to restructure clinical teaching, with the involvement of the entire Institution. In this context, it is difficult to rethink the curricular organisation of a Clinical Subject, preserving the desirable balance between a changing context and the need for pedagogical stability. From the conceptual point of view, the predominantly biological models of the disease were replaced by holistic and ecological models (biopsychosocial model), integrating epidemiological, psychological and sociocultural variables, while valuing the multiple co-determinants of health and disease. Medicine is increasingly focused on the patient, rather than on the disease. All of these factors have a decisive impact on pre- and post-graduate medical education. The “pluripotential” physicians of the future should have a global background in the clinical, scientific, and humanistic areas, as well as in communication, health management, teaching and research.

The Pre-Graduate Teaching of Paediatrics takes into account the characteristics of Paediatrics as a medical speciality aimed at a specific age group and the guiding principles of Medical Education, integrating two key aspects: Health and Well-Being, and Disease. But the main challenge will lie in the practical adequacy and applicability of a programme to an institutional and national reality, reflecting emerging trends. The teaching model will always depend on variables such as the number of students, the possible workload, the space available for teaching, the characteristics of the clinical services, the number and availability of the teaching staff. As Director of the Subject of Paediatrics, taught in the 5th year, in conjunction with Subject Coordination and with the inputs of professors and students, I have been promoting evolutionary adaptations in teaching, to reflect a changing context while aiming at high standards. I would emphasize: the increase of the student’s clinical exposure (qualitative and quantitative), including a higher number of practical and theoretical-practical classes; the improvement of professor/student ratios (reduction in the number of students per class, increasing involvement in teaching in affiliated hospitals); the percentage increase of practical/theoretical-practical classes based on clinical cases and on the discussion of problems; the decentralization and promotion of teaching in diverse contexts and clinical settings, the use of diversified teaching strategies, methodologies and techniques that provide the students with a greater exposure and more clinical training (including video-recorded lessons, emergency theoretical-practical classes, classes with models/simulation).

How have you been reconciling clinical and academic activities? It can’t be easy…

Indeed, it has never been easy and it never will be.

In short: work, work, work…and also,…organisation and good time management skills.

Throughout these stages, the challenges and demands have inevitably been increasing, both in the area of care, and in the area of research and medical training (Pre-/Post-Graduate); for example, at a certain point, I became responsible for various subjects (Introduction to Children’s and Family Medicine, Paediatrics Module VI II, Optional Subject of Paediatrics), for the Coordination of the Research Centre of the Paediatrics Department, for the Presidency of a Scientific Society and, last but not least, for research activities. In fact, my curiosity and taste for scientific research, together with the challenges and uncertainties inherent in the medical profession, encouraged me to get involved in clinical research early on. The years of intense study, work, and clinical and academic experiences, despite the recognised vicissitudes of the (persistent) lack of definition of an institutional model for the clinical professor and researcher, have been extraordinarily rewarding. Following the PhD in the area of paediatric infection by Helicobacter pylori and integrated as a Guest Researcher at the IMM Clinical Immunology Unit, I have been devoting particular attention to the area of ​​gastrointestinal mucosal immunopathology and bacteria-human host interaction. In this context, and with the goal of validating specific techniques for identifying H.pylori and immunohistochemistry in biopsy material, I’ve established collaboration protocols with national reference groups (HSM Pathological Anatomy Service, INSA) and international reference groups (Bordeaux) and I’ve carried out internships and study visits at reference centres (Gothenburg, Bordeaux, Instituto Gulbenkian de Oeiras), which were decisive to push ahead the ongoing projects.

As a Physician who has never interrupted her clinical activity, I consider my research background illustrative of a non-ideal model of scientific development for a clinical researcher. Indeed, I was faced with constraints in reconciling the demanding training of the speciality internship and the teaching activity with research. I was only able to do that once I had completed my speciality training. Then I started my PhD in my area of interest, funded by the Ministry of Health. Like other colleagues, I’ve personally experienced the difficulties inherent to the need for obtaining specific and representative randomized cases and biological material in advance (there was no biobank at the time), as well as the lack of time allocated specifically to research (working a lot of overtime). This model of physician-scientist (“an endangered species,” as Wyngaarden said), in addition to freelancing, as was the case with many clinicians of my generation, is unacceptably long and hardly compatible with the development of internationally competitive research projects; however, I find clinical experience and maturity very important for the autonomous development of clinical research. Currently, the scenario is much more favourable, as hospital institutions are provided with incentives to foster research activities and some institutional flexibility, so as not to waste vocations. The doctoral-intern regulation, as well as incentives from universities and private foundations aimed at providing advanced scientific qualification to new generations of physicians, are examples of that.

A substantial part of my career has been dedicated to post-graduate education. I’ve been developing this area of academic life in various contexts, including participation in Master’s Study Programmes, PhD Programmes, Advanced Training Courses, Service Training Sessions. It also includes support and supervision in the presentation/publication of papers (free communications, publications including case-by-case reviews, clinical cases and original works), as well as the integrated training of Interns of various levels, the Specific Internship and the Common-Year Internship of Hospital Assistants, in addition to 6th-year Vocational Training Tutor. It has also been a privilege to be the Training Advisor of the Specific Paediatrics Internship since 1999, at the invitation of the Interns. As the paradigm, par excellence, of the role of the clinical Mentor – guiding, as role model, the overall career of the interns – it has been a demanding but very stimulating and rewarding activity in the threefold care/education/research area.

Although all these activities are complementary, synergistic and mutually empowering, there is still some personal frustration with this model of academic career: the difficulty in maintaining the desirable regular rhythm of scientific production. Indeed, the fact that there are multiple and absorbing competitive activities significantly reduces the time we can dedicate to that (despite the accumulation of relevant clinical-scientific elements for publication). The early involvement of young interns, young specialists and students in research projects developed by the services (whether or not included in Doctoral Programmes or Special Studies Cycles) will be decisive for developing clinical research. I have been, and always will be, a full-time clinician, regardless of my simultaneous dedication to teaching and research. Therefore, in my case, I would like to stress the key role that assistance and clinical experience accumulated over many years have played and will continue to play. With all its demands, richness and diversity, it is the core of all my academic activity, promoting and fostering quality in teaching, research issues, the development of clinical/translational research projects and scientific production.

As Director of Paediatrics at the Faculty, you are the Pedagogical Coordinator of the 5th year. As students gain scientific knowledge, do they become more demanding with their Professors?

We expect that to be the case, taking into account not only the cumulative knowledge, but also the skills, competences and, above all, the intellectual and clinical maturity gained from the beginning to the end of the study programme. The training of future physicians as active, critical and empathic members of society begins at the pre-vocational stage. Through a transformative education based on a culture of professionalism, students will gradually develop relational (and not only communicational) capacities, an ethical attitude, , as well as a commitment to responsibility and demand/excellence in their learning and practice. In terms of scientific knowledge, the integration in the pre-graduate curriculum of medical advances and research opportunities will promote a more comprehensive and critical perspective, encouraging, for example, the early emergence of the physician-scientist profile.

In fact, Medical Education, which has both graduate preparation and vocational training components, is truly representative of the University’s role in inspiring exceptional physicians and future leaders. The commitment of the Faculties of Medicine is key in the construction of the identity of the future physicians and of an individual professional career. Indeed, the School as a whole, including “ecological” factors (values, culture, behaviours – “the spirit of the school”), represents a true role model for teaching, care provision and research, in an atmosphere of individual and collective commitment. In this context, I would like to emphasize the outstanding contributions and praiseworthy performance of our students in the various activities developed by the School, participating, with great pride, competence and proactivity, in the respective bodies (such as, among others, via satisfaction surveys regarding teaching). These contributions are equally well illustrated in the portfolio of initiatives and activities developed by the FMUL Student Association, of which our School is very proud. These aspects are extremely important, as factors that promote educational progress, from the perspective of teaching, research or academic/institutional management activities.

For me personally, being responsible for a core (Module VI II) and optional subject such as Paediatrics, taught in the 5th year, as well as for academic management duties, namely in the Pedagogical Board (until 2017), in the Pedagogical Coordination of the 5th year, and in the Clinical Teaching Implementation Committee, an interface for dialogue with the students (Course Commissions, Year Commissions, etc.), have been demanding and stimulating challenges, balancing what would be desirable with what is achievable. Thanks to a process of permanent reflection and institutional dialogue with all the stakeholders (professors, students, members of the secretariats and other management bodies of the faculty), we create synergies that are crucial to continuously improve the educational process and to foster the spirit of the School. The Subjects in the area of Paediatrics (comprising 3 Core Curriculum Subjects, the Vocational Clinical Internship and 2 Optional Curriculum Subjects) involve a large number of students (more than 1300 in 2017, including Erasmus students) and teaching staff. Its proper functioning requires a high level of organisation and, in this context, it is important to highlight the competence and exceptional work developed over the years by the person responsible for the Subject secretariat, Paula Belmonte (BAD-FMUL), providing support to both Pre- and Post-Graduate Teaching.

I would also like to emphasise how important a sound pre-graduate paediatric training core is today, with regard to the activity of future physicians, particularly in view of the restructuring of medical careers with the proposed transition of students from vocational internships to specific internships. It is estimated that a high percentage of future physicians will be involved in the provision of paediatric care (such as paediatricians and general practitioners). In the teaching of Paediatrics, the educational outcomes, models and strategies should reflect the vertiginous evolutionary dynamics of both core and clinical knowledge, of evidence in educational sciences, of the organisation of healthcare structures and the needs of the populations. The evolution of pathology and care organisation, for example, has important implications for pre-graduate training. In fact, in the context of a tertiary hospital, by definition, the provision of care has a complex, transdisciplinary nature, reflecting the major contribution of chronic diseases. Students would hardly have the opportunity to deal with the broad spectrum of normality; with regard to exposure to the diversity of pathologies in the various paediatric age groups, the aforementioned constraints raise the need for an elaborate and strict planning of contents, methodologies and teaching scenarios, in order to meet the training goals. Lastly, having contact with students as part of their Master’s Theses (supervision, panel) has also been a very rewarding and informative experience. Preparing a Mentoring proposal for the FMUL in collaboration with two students was also a very productive team work. I acknowledge that, in medical education, Academic Mentoring Programmes, with strong student involvement, may play an important role in pre-graduate training and in creating educational models, as key instruments in the process of personal and professional development.

How important is it to be on the Ethics Committee? Can you implement ideas and change values?

The Ethics Committees (ECs) we have in hospitals and Academic Centres are undoubtedly important institutional pillars in the noble mission of protecting the ethical, deontological and humanistic values inherent to the pursuit of care, teaching and research activities, as examples of integrity, precision and excellence. However, their current sphere of action is much larger than one might think “a priori,” including not only advisory and normative duties, but also, above all, reflective and “educational” duties in a broad sense. Issues in the field of bioethics, which are becoming increasingly complex in view of the vertiginous developments in technical-scientific knowledge, health models/systems, clinical and research practices (which are increasingly “anticipating” emerging sociocultural paradigms and vice-versa), require new “perspectives” and approaches to the decision-making process in ethical problems/dilemmas and conflicts of values (and to the development of regulations). In this context, the role that is currently played by the ECs entails a great deal of openness to the contemporary reality of the societies in which they operate, reflecting the emerging changes and being mutually decisive and innovative in their promotion.

The CAML/HSM-CHLN Ethics Committee, whose members have different backgrounds, expertise and perspectives (their great wealth and added value) is, par excellence, a privileged forum for a broad intra- and inter-institutional dialogue focused on bioethical reflections and decisions, an exemplary model that has a truly transdisciplinary nature and goes way beyond mere technical duties. On a personal level, working on the Committee has given me a very broad and realistic “on-site” perspective of the current ethical dilemmas and contexts inherent to the practice of research in several areas of knowledge (not just paediatric), their potential and constraints. Above all, it has been a unique professional and humanistic experience and an exercise in constant learning and evolution (truly “food for thought”). In this context, I find the bioethical component in pre- and post-graduate medical training throughout the entire professional life cycle (continuous training) to be highly relevant today and, in my view, it deserves to be given greater emphasis in future training programmes (as a cross-cutting skill).

Are there medical cases you take home with you, that you can’t forget as soon as you leave the office?

The essence of the art of being a physician entails a holistic, humanised perspective and a relational approach to the patient and his/her family, educational, social “ecosystem”… and not simply automated gestures such as a therapeutic prescription for symptom relief. This medical premise is particularly evident in the role played by Paediatricians. In fact, you don’t forget your patients, or your service, or their problems! “You take them home,” you go and study a rare case, a diagnostic dilemma, the reason for the lack of therapeutic response, the latest pubmed evidence,…This is the everyday life of a hospital paediatrician, who is virtually “permanently available” (especially in clinical contexts that are particularly serious or complex), helping colleagues with their doubts, giving feedback and supporting the children’s families. In my case, the fact that I’m fully focused on my patients and my Service (which necessarily entails clinical management activities) was the result of my self-demanding stance when I chose to work in a hospital on an exclusive basis. Another extremely important component of the outcome is teamwork, focused on a close interaction between medical and nursing staff, especially in cases of chronic illness. The unique bond between the child/family and the paediatrician lasts forever. It is rewarding to be regularly visited by adults we followed as children/teenagers. We also acknowledge how difficult it is for some young people with chronic illnesses to make the transition to Adult Medicine, and we know we are often co-responsible for an attitude that is too “paternalistic” sometimes, and for the difficulty in “cutting the umbilical cord.”

If I asked you to describe the meaning of the word “child” with one word, what would you say?

The answer to this question (for which there are many answers…) always runs the risk being commonplace…but these two words contain much of the essence of Being a Child: “Dream” and “Resilience.” Both mean that everything is possible, that there are no insurmountable obstacles, and we transpose that to illness and the therapeutic process. That is why Paediatrics is so rewarding and why Paediatricians reflect much of the Children they were and they see every day.

Formally, it was only in 1989, with the Convention on the Rights of the Child (UN General Assembly), that the concept of “Child” as a person under the age of 18 was “approved.” Paediatrics, as a Medical Speciality aimed at a specific age group and addressing the developing human being, was broken down into subspecialties to respond to the multiple needs of its target population, while never losing sight of the essence of paediatrics: human beings with a biopsychosocial individuality in successive developmental stages as different as the perinatal period, preschool age, school age and adolescence. As a medical speciality and a comprehensive subject, it integrates all aspects of the health and well-being of Children/Youths and their stages of growth and development throughout their life cycle, as well as specific, acute and chronic pathologies. Today, the role of the Paediatrician, focusing on ever-changing human beings, as well as on the role played by parents in clinical triangulation, includes advocating for the children’s needs and the promotion of their best interest. And despite all the extraordinary advances in biomedical science and futuristic scenarios (impact of decoding the human genome and recombinant technology on strategies for prevention and personalised treatment, control of infectious and non-infectious pathologies, improvement of survival and quality of life), which will inevitably be reflected in Paediatrics, the interpersonal dimension of the physician-child-family relationship should remain the essence of the art of being a Paediatrician/Physician.

Not wanting to trivialize the topic, I will limit myself (et pour cause) to the obvious: “The Child is the future of Man.” In this context, health policies aimed at paediatric patients with an impact on adults are rather important. Although children don’t vote, they should be at the core of all policies (economic, social, environmental,…) and not just of health policies. In fact, this “ecological” perspective underpins the organisation of life-cycle health programmes (starting with the prenatal period). It is the broad metaphor of it taking a “whole village” to raise a child. As we know, the emphasis on the most vulnerable groups (children, the elderly,…) is a hallmark of the most advanced societies. The profile of paediatric pathology has been changing over the last few decades, as illustrated by the developments in the main health indicators. On a global scale, paediatric mortality is still attributable to preventable causes (acute respiratory disease, diarrhoea, malaria, HIV/AIDS infection, malnutrition). In wealthy countries, despite the drastic reduction of mortality in the first year of life – due to improved perinatal care and control of infectious diseases – mortality due to preventable external causes, such as road accidents, and morbidity due to chronic illnesses (e.g. widespread growth of atopic disease in industrialised countries) remain at high levels.

Obesity, oncological diseases, and social or behavioural pathologies (depression, risk behaviours) are becoming a major concern. Chronic diseases have increased in all age groups, with the inherent problems of therapeutic adherence and transition to adult services, as well as the prevalence of children with disabilities or special needs. Another relevant aspect is the recognition of early determinants (intrauterine growth restriction) of adult pathologies (obesity, diabetes, cardiovascular disease). These are telling examples of the relative weight that environmental/epigenetic factors will have at present and in the near future and of the extremely important role played by prevention and education for health in this context. Portugal has unquestionably reached indicators in the area of ​​maternal and child health that are identical to those of the most developed countries in the world, being acknowledged as a success story. These great achievements of the last 30 years are mainly the result of specific programmes focused on maternal and infant health. These aspects, particularly the investment in early prevention, development and vulnerability throughout the life cycle, have been resulting in a redefinition of health priorities, with an impact on the contents of Pre- and Post-Graduate Medical Education.

Returning to the initial question (to define “Child” in two words), and to conclude, I refer simply to Fernando Pessoa’s eloquent symbolism: